© 2012 Mayo Foundation for Medical Education and Research

What is the likelihood of documented pain assessment with RN involvement?

Odds Ratio

Confidence Interval

p-value

Unadjusted 35.75 6.75 – 660.84 <.0001

Adjusted for pain score

33.89 6.36 – 627.74 <.0001

Adjusted for pain score and Pre/Post

11.60 1.96 – 222.84 .0043

Adjusting for differences in presenting pain score and study factors, documentation of pain assessment is 11-12 times more

likely if an RN is present compared to not being present

Results % Charts with Documentation of Comprehensive Pain

Assessment before and after implementation

Clinical Practice Question In adult oncology patients in an outpatient Medical Oncology clinic in a large Midwestern academic medical center, does the use of a registered nurse (RN) during the outpatient care visit for those patients with sarcoma or head/neck cancer presenting with a pain score of ≥4, compared to current practice without involvement of an RN, result in improved documentation of a comprehensive pain assessment reflected in the electronic medical record (EMR)?

Clinical Problem: Cancer-related Pain •  Common: Prevalence rates of 33% - 71%

(McNeill et al., 2004; Ripamonti et al., 2011; van den Beuken-van Everdingen et al., 2007)

•  Undertreated: Estimated 43% of patients with pain receive inappropriate care (Deandrea et al., 2008)

•  Concern: Contributes to reduced quality of life for patients and their families (Portenoy, 2000)

•  Regulatory agencies mandate for screening and treatment of pain at the time of every outpatient visit (JC, 2009) •  Retrospective chart review of clinical site revealed documentation rates of 18% for comprehensive pain assessment

(see handout for needs assessment tools)

Review of Literature

�  Evidence-Based Practice Model: Iowa Model of Research-Based Practice

(White & Dudley-Brown, 2012) - ‘triggers’ spark investigation

- supports use of pilot testing �  Middle-Range Nursing Theory:

Theory of Symptom Management (Humphreys et al., 2008)

- symptom experience - management strategies - outcomes

�  Knowledge Translation Model: Promoting Action on Research Implementation in Health Services (PARIHS)

(White & Dudley-Brown, 2012) - evidence / context / facilitation

Theoretical Framework

Cost / Benefit Analysis

Documentation of Comprehensive Pain Assessment in Outpatient Medical Oncology – Best Practice

Michelle K. H. Wald, MSN, RN, CNP 1,2 Faculty Advisor / Committee Chair: Julie Ponto, PhD, RN, ACNS-BC, OCNS 1 Clinical Preceptors: Steven Alberts, MD 2; Marlea Judd, DNP, RN, CRNA 2

1 Winona State University, Rochester, MN; 2 Mayo Clinic, Rochester, MN

Intervention or Evidence

* Level of Effectiveness

** Level of Evidence

Key References

Regulatory, Practice, and Quality Guidelines

Effective Level II JC, 2009 Effective Level II Lorenz, 2009 Effective Level II Swarm, 2009

Involvement of Nursing Role

Poss. Effective Level III Borneman, 2010 Poss. Effective Level III Borneman, 2011 Poss. Effective Level III Campbell, 2008 Poss. Effective Level IV DuBose, 2009 Poss. Effective Level III Dulko, 2010 Poss. Effective Level IV Gracias, 2008

*/**Ackley et al., 2008 •  Level of effectiveness / evidence reference guide and

complete reference list available on handout

Synthesis of Literature •  Guidelines for management of cancer-related pain and quality indicators for supportive care are available •  All mandate performance of a comprehensive pain assessment as the basis for therapeutic decision-making •  Involvement of nursing in assessment / monitoring / evaluation of pain and patient education can result in increased

adherence to clinical guidelines and improvement in patient-reported pain scores

Stakeholders •  Can directly or indirectly influence the change process

(Porter-O’Grady & Malloch, 2011) •  Early identification and involvement critical to successful

implementation •  Nursing representatives from multiple levels

- Complexity of role •  See handout for list of stakeholders

Readiness for Change •  Facilitators:

ü  Institutional Culture - change valued / constant

ü  Practice Setting - invested in providing quality care - multidisciplinary practice model - recent introduction of RN role

•  Budget -  Outpatient RN salary: $59000 - $61000 annually

(www.mayoclinic.org/jobs-nursing-rst/faqs.html#pay) -  Average 1-2 patients per day / 10 minutes to complete -  RN costs of pilot = 2-4% of annual salary

-  No additional costs incurred

•  Societal Impact of Cancer-related Pain -  More pain-free with guideline-based care (GBC) vs.

oncology-based care (OBC) or usual care (UC) -  Incremental Cost Effectiveness Ratio (ICER)

-  GBC vs. OBC = $452 / OBC vs. UC = $601 (Abernathy et al., 2003)

-  If pain relief during course of prostate cancer … -  0.85 quality-adjusted life years (QALY) added -  Welfare loss of $109,116,000 (U.S.) per year (Sennfält et al., 2004)

Current Evidence

Key Words Restrictions Number of Hits CINAHL OVID PubMed Cochrane NGC

‘oncologic care’ ‘cancer pain’ ‘palliative care’ ‘symptom management’ ‘pain management’ ‘practice guideline’ ‘implementation’ ‘guideline adherence’ ‘nursing role’

‘English language’ ‘Peer reviewed’ ‘Publication type’ abstract journal article meta analysis practice guidelines systematic review 2005 - March, 2012

541 149 258 412 353

•  Search Results Excluded: duplicate citations, pediatric population, nursing home or inpatient settings, alternative pain therapies, physician-assisted suicide, patients with dementia Quality review: Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument (2009), systematic review assessment tool (Duffy, 2005), research quality review tool 60 relevant resources remained

• Approved by Mayo & WSU IRBs • Strategy for Implementation

ü  Preparation - Completed baseline retrospective chart audit - Presented audit results and overview of pain literature - Conducted baseline provider survey - Developed documentation / assessment tools (see handout for supporting materials)

ü  Implementation - Three-week pilot

- Sarcoma or Head/Neck diagnosis - patients reporting pain score ≥ 4 - clinical assistant notified RN - RN performed comprehensive pain assessment - reported to provider / documented in EMR - Outcome measurement through chart audit - Results presented to department leadership

Methods Criteria for Success: • Evidence

- Planned update of literature review - Ongoing assessment of quality of care � periodic chart audit (w/ feedback)

• Context - Ongoing practice support and reinforcement � monitor / analyze effectiveness of organizational structure and process � educational in-services (RN / Staff)

• Facilitation - Assess ‘readiness to learn’ of all constituents - Presence of ‘champion(s)’ - Evaluate resource allocation (RN and other)

Future Plans: • Identified as need for continued practice quality improvement • Evolving discussion of how to best identify patients / utilize RN

Practice Implications

n = Pre = 4 of 12 Post = 18 of 28

Pre = 0 of 13 Post = 13 of 21